Prescription

 
Patient's Name

 

Date  
Diagnosis    
Physician's Signature   Phone  
     
Compression (select one): Products:

No Substitution

15-20 mmHg Samson & Delilah
20-30 mmHg Cotton-, Truly Transparent-, Select Comfort-
30-40 mmHg Cotton-, Natural Rubber -, Select Comfort-
40-50 mmHg Natural Rubber

Number of Refills______

50-60 mmHg Natural Rubbert
   
 
Style (select one):  
 
Calf Pantyhose Maternity Pantyhose
 

Thigh

 

Thigh with waste attachment

Right

Left

Armsleeve

with gauntlet

without gauntlet

       
       
         

PHYSICIAN MEDICAL SUPPLY, INC.

6765 Lake Side Circle East

Worthington, OH  43085

(419) 945-2980

Fax: (419) 945-2981

COMPRESSION LEVEL

AT THE ANKLE

INDICATIONS

NOTE;  ANY LEVEL CAN BE USED FOR TRAVEL ACCORDING TO DIAGNOSIS

15-20 mmHg

  • Heavy, fatigued, tired legs

  • Prophylaxis during pregnancy

  • Prophylaxis for legs predisposed to risk

  • Long hours of standing or sitting

20-30 mmHg

  • Heavy, fatigued, tired, aching legs
  • Mild varicosities during pregnancy
  • Mild varicosities with minimal edema
  • Minimal edema upper extremities
  • Post-sclerotherapy of small veins

30-40 mmHg

  • Moderate to severe varicosities with mild edema during pregnancy
  • Mild varicosities with moderate edema
  • Post fracture, Post traumatic edema
  • After sclerotherapy or phlebectomy of larger veins or after vein stripping to maintain treatment success
  • Primary venous ulcer treatment
  • CVI Grades I and II*
  • DVT or Post Thrombotic Syndrome
  • Mild primary lymphedema after decongestant therapy to maintain reduction, secondary lymphedema or moderate edema of the upper extremities

40-50 mmHg

  • Severe varicosities
  • Severe edema
  • Primary and reversible lymphedema after decongestant therapy for reduction maintenance
  • Pronounced CVI (Grades I and III*)
  • Severe Post traumatic and Post fracture edema
  • Recurrent venous ulceration (Grade IIIa)
  • Severe Post-Thrombotic Syndrome

50-60 mmHg

  • Primary lymphedema after decongestant therapy for reduction maintenance
  • Severe Post-Thrombotic Syndrome (PTS)

CONTRAINDICATIONS

CAUTION

  • Arterial insufficiency, intermittent claudication, ischemia
  • Uncontrolled congestive heart failure
  • Acute dermatitis, weeping dermatosis, cutaneous sepsis
  • Signs of infection
  • Extensive venous ulceration
  • Skin sensitivities or allergies
  • Neuropathy
  • History of diabetes
  • Confinement to bed or non-ambulatory use unless otherwise prescribed by the physician

No liability accepted for non-observance of contra-indications and cautions.

* According to Widmer & Marshall

www.sigvaris.com

 

=SIGVARIS is a registered trademark of Ganzoni & Cie AG, St. Gallen, Switzerland

=2004 Ganzoni & Cie AG, St. Gallen, Switzerland